Ag Worker Access 2020: Increasing access to quality health care for Migratory and Seasonal Agricultural Workers

By Bobbi Ryder, CEO, National Center for Farmworker Health, Co-Chair, Ag Worker Access 2020 Campaign Task Force and Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

Federally funded health centers (“health centers”) serve an estimated 18 percent of the country’s migratory and seasonal agricultural workers.  Specific health center program funding to serve this special population and decades of health center history in doing so have provided hundreds of thousands of agricultural workers with health care. Behind the starkly low figure stand thousands more agricultural workers and their families who may lack access to services that are offered specifically to serve their needs. Some may be receiving care at health centers but are not being properly identified, which is problematic: A clinician’s approach to care must take into account the circumstances of a patient who plans to migrate soon, or the occupational hazards of agricultural work.  And a funder’s view of the numbers may beg the question: Why do health centers need the current level of funding to serve agricultural workers, if so few are reportedly seen?

Over the last two years, the National Center for Farmworker Health (NCFH) and the National Association of Community Health Centers (NACHC) have brought health center leaders and migrant health advocates together to rectify this issue. Participants zeroed in on several ways to better serve and identify agricultural workers during roundtable discussions.  In May 2015, at NACHC’s Annual Farmworker Health Conference, a call to action was issued.  The resulting Ag Worker Access 2020 campaign has been embraced by both NCFH and NACHC and a coordinating task force has been appointed by the NACHC Ag Worker Committee.  The campaign’s 11-member task force is appointed by the NACHC Ag Worker Committee and co-chaired by Ryder and Avein Tafoya, President and CEO of Adelante Health Care in Phoenix, AZ.  The campaign identifies important approaches to improving access, and offers the tools and technical assistance needed to implement them. The Ag Worker Access 2020’s goal is to increase access to quality care for agricultural workers in health centers over the next five years, and serve at least two million by 2020.

The progress has already been noted in 2014, and members of the Ag Worker Access 2020 task force anticipate further growth of services in 2015 -- the results, they believe, of the nationwide effort.  The campaign has the following three broad strategies to effect change:

1. Credit where credit is due: Identifying agricultural worker patients

The first strategy focuses on helping both the administrative and clinical teams in identifying a patient as an agricultural worker. Under this strategy, nicknamed “credit where credit is due,” health centers take measures to accurately identify the agricultural workers currently being served but not properly identified as such in the electronic practice management system or EMR.  The meaningfulness of data collection is lost when a patient is not properly identified in the EMR and accurately reported to the Uniform Data System (UDS), the system under which health centers report their progress to the Health Resources and Services Administration (HRSA).  Accurate information on migratory and seasonal agricultural workers cannot be extracted from important data collection systems when the reporting is compromised.

Identification of special population status must be understood as independent of the determination of sliding fee scale eligibility or verification of insurance coverage.  When population status is treated as an insurance category, and a patient shows up with third party insurance, registration staff may miss identifying the patient as migrant or seasonal because they have already identified the insurance category.  Yet, all federally funded health centers are required to identify the special population status of all patients: migratory or seasonal, homeless, veteran, or public housing.  If that step is skipped, vital patient information may not reach the exam room.  If, consequently, a provider does not know that a patient is engaged in agricultural employment, the provider may not properly recognize, manage, or diagnose agriculture-related injuries or exposures, or provide the patient with education on how to manage risks the patient may face in agricultural settings.

Awareness of migratory status is also important for clinicians to know.  A provider who does not know a patient is planning to migrate in four months may launch into a major dental repair which cannot be completed, or fail to provide a multi-month prescription birth control which may lead to unplanned pregnancy.  As some agricultural workers need to migrate to seek work through the seasons, uncovering agricultural status is the first step in determining migratory status.

One point often overlooked among health centers is that former migratory workers, no longer able to work because of age or disability, should be counted as agricultural workers, along with their families.  The statute does not define age or disability; whether the worker is 50 or 60 years old, or fully or partially disabled, if age or disability prohibits a former migratory agricultural worker from working, then that person should be identified as an agricultural worker.

The term “families,” which is used in the statute, may be misinterpreted as limited to legal dependents when in fact it includes extended family members.  “Family members” may also include those in domestic partnerships and common law relationships.

How the question is asked is as important as the question itself, as NCFH points out in a fact sheet on identification of agricultural workers: “When describing their occupation, the majority of the agricultural [workers] seldom identify themselves with the terms migrant, seasonal, aged, or disabled. They tend to describe themselves either by the product they are working on, by the task they are performing, or by the location of their employment.” Or, a migratory worker may have finished migrating for the year, and may have taken other temporary employment in his or her home base -- and consequently may not self-identify as an agricultural worker in the intake prompts. Intake questions need to ask about recent work history as well as current. Those with the intent of employment in agriculture, but not currently so employed, also fall in the category, even if they have not worked in agriculture within the last two years, notes the NCFH fact sheet.

Finally, staff need to understand -- and internal health center policies must reflect -- the complete definition of what agricultural work is. (See sidebar for complete definition.)

Ag Worker Access 2020 is helping health centers tackle these issues. Through a partnership with the Central Valley Health Network (CVHN) in California and the Washington Association of Community and Migrant Health Centers, NCFH has provided training to health centers in central California and Washington, and has offered a program that will facilitate standardized training and retraining of front desk staff so that as turnover occurs, health centers can assure accuracy and consistency in front desk procedures. The training is also intended to be provided to new employees as part of standard orientation.

Additionally, executive staff must assure that its health center’s policies are in tune with the data requirements for the UDS outlined by HRSA.  NCFH assistance in reviewing health center policies and protocols to assure alignment with the statute and the UDS Guidance manual.

Application of this strategy is not limited only to health centers that receive funding specifically to serve agricultural workers; all health centers need to ensure proper identification of patients.

2. Access for unserved agricultural workers

The second strategy, “opening doors and increasing access,” asks health centers to take a fresh look at the community to see if there are pockets of agricultural workers that have been overlooked due to changes in agricultural industry.  Health centers are encouraged to engage community partners like community advocacy organizations, Migrant Head Start and Migrant Education, churches, and food banks.  Migrant Health Centers (MHCs) may also find expertise in their neighboring health centers to help them build capacity to serve agricultural workers.  

Health centers should be sure to include agricultural workers in patient satisfaction evaluations, to determine how an agricultural worker perceives care, and why some do not receive care at the health center.  Organizations participating in the Ag Worker Access 2020 campaign will be working with promotores to assure that agricultural workers know their right to be seen at health centers, and encourage them to exercise that right by becoming patients.

NCFH and NACHC offer training to assure that governing boards take responsibility to assure that the health center’s migratory and seasonal agricultural workers are appropriately served and welcomed. Health centers need to actively assure that their own processes and procedures reduce subtle acts of discrimination that create unintentional barriers to access.

3. Building and increasing capacity

The third strategy will anticipate health center growth, and reach out for funding from a variety of sources early on in the process.  Ag Worker Access 2020 campaign advisors recommend thinking about how to support growth through the lens of the managed care environment, even though it is not, for the most part, a managed care population.  To sustain growth, one recommendation is to create a per-ag-worker-per-month revenue stream that is attached to growth.  That funding should be dedicated to assure integration of outreach, case management, patient navigation, and bilingual services as critical elements of a standard practice management system.

Conclusion

Migratory agricultural work is dynamic, and the changes occur without advance notice in response to weather, economics, and demand for commodities. Tracking these changes with reported figures is challenging because they occur faster than the data can be gathered and reported. The most current and accurate knowledge of agricultural worker demographics is often anecdotal. Health centers need to actively engage their own boards, and their administrative and clinical teams within each of their local communities, to assure flexibility in services to best respond to the ever-changing needs of this special population.  

The Ag Worker Access 2020 campaign invites individuals, health centers, organizations, and employers to take part in this effort to assure that the intent of Congress, in authorizing the Migrant Health Act in 1962 and the Community Health Center Act in 1967, is upheld for the next 50 years.

RESOURCES

Visit the Ag Worker Access 2020 website at http://www.ncfh.org/ag-worker-access-2020.html.  Contact key coordinators of the Ag Worker Access 2020 campaign to learn more about training and technical assistance: Bobbi Ryder, ryder@ncfh.org; Joe Gallegos, jgallegos@nachc.com, and Alicia Gonzales, gonzales@ncfh.org. 

National Center for Farmworker Health’s fact sheet, entitled “Agricultural worker status verification: Introduction and points to remember” is available at http://goo.gl/Mlkelr.  NCFH offers example policies and procedures at: http://www.ncfh.org/ag-worker-access-2020.html.

The North American Industry Classification System is viewable at http://www.census.gov/eos/www/naics/. 

NACHC’s My Learning Community offers a special “community” specifically on Ag Worker Access 2020: http://mylearning.nachc.com. 

What is agriculture work, anyway?

According to HRSA’s 2015 UDS Manual, the term “agriculture” means farming in all of its branches as defined by the North American Industry Classification System, a program of the Office of Management and Budget that standardizes tasks for use by Federal statistical agencies in developing data related to the US business economy.  In most cases, “cultivation” is the key word, which is why industries not cultivating the product -- like fishing and hunting, or like processing of harvested food -- aren’t included in the HRSA definition of agricultural workers.   Keeping these intricacies and exceptions in mind, here’s a short list of what constitutes employment in agriculture, and the corresponding NAICS code:

• 111: Crop Production
• 1111: Oilseed and Grain Farming
• 1112: Vegetable and Melon Farming
• 1113: Fruit and Tree Nut Farming
• 112: Animal Production and Aquaculture
• 1121: Cattle Ranching and Farming
• 1122: Hog and Pig Farming
• 1123: Poultry and Egg Production
• 1151: Support Activities for Crop Production
• 1152: Support Activities for Animal Production

Please note that this list includes both horticulture and animal husbandry. “Support Activities” include transportation from the farm to market or to a processing facility not located on the farm.

Some activities that are NOT considered “agricultural” include the transportation of meat and meat products, merchant wholesalers, landscaping, spectator sporting (like care of racehorses), and lumbering or transportation of timber. NCFH further breaks down the definition and its inclusions and exceptions here: http://goo.gl/t1ixUp.